Use of a Mobile Lab to `Test the Waters` at a Rural Hospital

Can you describe your hospital and the type of population you serve? We are a 99-bed acute care hospital located in Dodge City, Kansas, which is in southwest Kansas. Western Plains Medical Complex is a rural hospital; we are 150 miles west of Wichita, which is the closest major metropolitan area. We serve a population of around 200,000 between our primary and secondary markets. Our market goes all the way to Wichita in the central part of the state, north up to Nebraska, over and even into Colorado in the west, as well as down into northwest Oklahoma. It’s quite a diverse area. Why did your hospital decide to begin a cath lab program? Our population was underserved in cardiology. What we had were what I referred to as part-time cardiologists. Cardiologists, primarily out of Wichita, 150 miles away, came to do day clinics once every two weeks or so. If someone needed cardiac care, they had to wait to get an appointment from one of these cardiologists. This was just for those people who were looking to get a cardiology appointment, which in most cases would have been a referral from a primary care physician. It didn’t include people who had an urgent need, such as a myocardial infarction (MI), chest pains or other symptoms. Prior to our cath lab (mobile) opening, patients were administered thrombolytics and then transferred to other hospitals in Wichita. In effect, once you left Wichita, you had no full-time cardiologist in almost half the state of Kansas. That was the impetus behind our bringing in a full-time cardiologist. Of course, once you have an interventional cardiologist, they will need the technology to support their practice, which is why we got involved with CSI and began using a mobile cath lab. What requirements does the state of Kansas have to begin a cath lab program? We do not have a Certificate of Need (CON) in the state of Kansas, so it was up to the hospital to prove the need. In our case, LifePoint Hospitals, Inc. is our parent corporation out of Brentwood, Tennessee. Gaining the funding to both recruit cardiologists and to begin with the mobile cath lab was a matter of putting all the financial projections together. It was not a difficult task, because there was all kinds of data showing that patients were leaving the area and driving somewhere else for cardiac care, be that Wichita, 150 miles away, or Hays, Kansas, a little more than 100 miles away. That data was openly available through the Kansas Hospital Association and other organizations. Why incorporate a mobile cath lab? We were fortunate to have recruited an interventional cardiologist, Dr. Muhammad Khan. Yet we knew we couldn’t build a cardiac cath lab overnight. We had a need for a mobile service to come in and help us out so we could be up and running quickly. This led us to contract with CSI, who also offered us clinical and technical support. CSI provided extensive on-site clinical applications for staff upon installation. CSI’s clinical specialists also returned several times during the lease to re-train, following staffing turnovers.They brought in the startup mobile lab, which in our case was a GE Advantx LCV+ combination lab. It has a 12 image intensifier with spin, bolus chase and digital subtraction. Where was the lab located and how was it attached? We poured a cement pad and located it right behind our emergency room. Working with our local electrical supplier, we ran a special power source for the lab, so that it would have its own power source and not be dependent on the hospital for power. We also built an enclosed area between the mobile lab and the ER, which served a dual purpose: one part was storage space for the supplies and the other worked as a passageway, to go from the hospital to the lab and to keep the patients out of the weather. We do have our share of seasonal weather in Kansas. CSI had the very good option of a lab with what I would refer to as side entry, with a lift for the stretcher. You could roll the stretcher directly to the mobile cath lab, put the patient on the lift, raise them up three or four feet and then slide them right into the mobile cath lab and on the table very quickly. How long did it take to get the mobile lab set up and ready to go, and how long until you had your first patient? Once the delivery took place with the mobile lab, it was a very quick process. Once it was delivered to the site, within 4-5 hours, it was up and running. After that, we had to build the enclosure area I described to protect the patients from the weather. Building that area took a few days, but if not for that delay, we literally, with the help of CSI, could have been doing cases the next day, as long as we had everything else we needed. Our interventionalist knew the installation date, and the schedule of how many days we thought it would take to build the enclosure. It was just a matter of him having patients, but in fact he had already started attracting patients. Once he came to Dodge City and opened his doors, word traveled fast that he was here and would be able to see and take care of cardiac patients. How else did you get the word out to physicians and patients that you had this new capability? We did a lot of print ads. We also did television and radio. Dr. Khan himself went out to many service clubs and he also met with a lot of the primary care physicians locally and in the outlying areas, to let them know that we now had this capability. We did a lot of marketing in various forms. Did you need to hire new staff for the expansion? We sent some current staff to another hospital in Kansas to get training so we could get our staff up to speed fairly quickly. We also felt like it was in the best interest of the patient care we would be providing to have them trained in the appropriate setting, rather than it being on-the-job training. We also hired some staff with cath lab training, so it was a combination. Once you had the mobile lab set up, how soon did you begin treating acute MI patients? Once the mobile lab was up and running, we began treating MI patients right away, due to the level of training of our interventional cardiologist. We were able to use his expertise to assist through the initial cases while we were getting our staff trained both on-site and at the other hospital location which provided additional training of our cath lab staff. Originally, Dr. Khan was on call 24/7 for cases in the ER because at that time he was the only cardiologist. Also, he was very dedicated to getting the cath lab started and did not want any patient to be transported unless they needed open heart surgery. Helicopter and fixed wing service was available on a as needed basis from the beginning of the mobile lab operation. In January 2007, the helicopter service stationed a helicopter at our hospital, dedicated specifically to our patients. Your facility utilized the mobile lab for two years? Yes. It was installed in the fall of 2005, and we used it for almost two years. The last day the lab was physically on-site was August 10th of this year. We used it all the way up to August 6th. It was a long lease period, which allowed us to really go in a whole new direction in our hospital. We increased our capabilities in our other critical care areas, such as our ICU. The cath lab program sparked a building expansion project, and we built a brand-new 10-bed ICU to replace the previous 6-bed ICU. We also brought in a progressive care unit to help with patients that perhaps did not need intensive care, but needed a step-down unit between intensive care and regular medical-surgical care. Of course, we also needed to build up our radiology capabilities. We ended up bringing in a new dual-head nuclear medicine camera. Our patients generally start out with an office visit, have a stress test, and then have a nuclear medicine test. The cath option, unless they are having an MI, is really the last option to take care of their issues. The cardiologists usually try to use everything else in their arsenal, in terms of lifestyle changes and medication, before they just take them to the cath lab. Having a mobile lab allowed us to really test the waters during that first year or two, to make certain that once we had made that decision to go ahead with the building project, it would be properly utilized. There was no doubt once we got the mobile cath lab here and saw how it was being used. Soon it had become very obvious that we were going to outgrow our space if we didn’t do something to expand our capabilities in intensive care and progressive care on the nursing floors. Before we moved into the permanent cath lab and did our first case there on August 7th, we had done nearly 1700 patients in the mobile lab since October 2005. That is a volume that many cath labs, even those in an urban area, would feel fortunate to have. Being able to show such high volumes also gave us leverage with the ambulance transportation companies. We favorably negotiated contracts to bring in helicopter service. If a patient had an acute MI and it was determined that they could not use a stent or there was some other risk factor that did not look favorable for treatment in the cath lab, it allowed the cardiologist to make the decision to immediately get the patient on a helicopter to a tertiary care facility in Wichita for open-heart surgery. How often is the helicopter used to transport cardiac patients? A few times a month. Often the cardiologists have a pretty good idea of patient needs from previous testing. I don’t think we’ve had very many patients taken to Wichita as the result of an emergency from a cardiac cath. Years ago, you did see situations where patients would be taken to the cath lab, have complications and need to be rushed into open-heart surgery. But these days, with the changes in technology, the physicians are good about predicting that if they go further in a case it will cause a problem. They know when to pull out and get that patient ready for transport or to not attempt the case at all. How many staff are in the cath lab today? There are about 12-13 people total, with a mix of cath lab technologists and nurses. What is your (now permanent) cardiac cath lab like today? Currently we have one interventionalist and one invasive cardiologist. Dr. Khan was successful in bringing in a second cardiologist. We have one cath lab, but the way we built the area was such that we do have the ability to bring in a second cath lab at the appropriate time. We are doing over 100 cases a month in the permanent lab. The transition from the mobile to the permanent lab was seamless in the eyes of the public and the referring physicians. Once you have the capability, it’s not much of a difference between the mobile and the permanent lab. Some physicians may have a greater respect for a permanent lab that’s not in a mobile setting, but we haven’t really seen that to be the case. We had very good luck using the mobile lab and our patients have excellent outcomes. We have not had a single death in our cath lab since the start of service. We have an excellent cardiology team. The teamwork between our cardiologists and our medical staff as a whole has made all the difference. Ultimately, our partnership with CSI was very beneficial to the community we serve. John Walker can be contacted at john.walker@lpnt.net or tel. (620) 225-8401. Cardiac Services, Inc. is online at www.cardiacservicesinc.com or tel. (800) 722-5742.

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